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Breast Examination

Breast Examination and Diseases.

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Breast Examination

  1. 1. BREAST EXAMINATION P R E S E N T E D BY : M A R I YA M S H A K I L
  2. 2. • OBJECTIVES: •History taking of breast disease • Breast Examination • Recording and investigations • Benign and malignant breast diseases • Differential diagnosis
  3. 3. HISTORY TAKING OF BREAST DISEASE • 1-Age : • * Less than 30 years. * Older than 50 years • 2- Residence: • 3- Lump : • * Duration since lump first noted * Consistency of lump presence * Change in size * Location * Shape * Rate of growth * Associated with menses, discharge, nipple retraction, tenderness ,dimpling and tender lymph nodes. • 4- Pain : • * Site ,Onset ,duration ,intermittent?* Character of pain * Associated with menses -timing and severity * Associated symptoms -lump or any discharge Contributing factors -trauma ,strenuous activity * Radiation – does the pain move anywhere else? * Exacerbating / Relieving factors – does anything the pain worse or better?
  4. 4. • 5- Nipple discharge : • * Color * Unilateral or bilateral * Any associate mass • * 6- recent nipple inversion: • 7-eczema ,dimpling ,ulceration: • 8-evidence of systemic disease: • Past medical history: • Relevant obstetric/gynecological history: • * Age at menarche/menopause: • Parity: • * Age at first pregnancy • * Did they breastfeed? • * Use of hormonal replacement therapy or oral contraceptive pill • Relevant past medical history:
  5. 5. • :* Recent breast trauma – fat necrosis • * Previous breast disease – malignant or benign? • * Any other previous malignancies? • * Other significant medical problems? • Surgical history: • – breast surgery / other surgery • Family history: • Family history of breast disease in the family.
  6. 6. BREAST EXAMINATION
  7. 7. RECOMMENDATION • A L L W O M E N O F AG E 2 0 A N D O L D E R P E R F O R M B S E O N A M O N T H LY B A S I S • A L L W O M E N O F AG E 2 9 TO 3 9 S H O U L D H AV E C L I N I C A L E X A M I N AT I O N E V E R Y 0 3 Y E A R S . • A L L W O M E N AG E S 4 0 A N D O L D E R H AV E R E G U L A R ( E V E R Y 0 1 TO 0 2 Y E A R S ) M A M M O G R A M S .
  8. 8. GENERAL: • All examiners should normally be chaperoned • The texture of normal breast tissue varies from smooth to granular, also varies with menstrual cycle and during pregnancy. • Nodularity and tenderness often increases towards the end of the cycle and during menstruation • Always examine both the breast and compare the two
  9. 9. INSPECTION: • The patient should be fully undressed to the waist, with upper body raised 45 degree to the legs. • BREAST: • Size • Symmetry • Shape • Skin color • Lumps • Skin tethering • Prominent veins and edema with dimpling like (peau d’orange) • Nipples: • Everted , flat, or inverted (recent or longstanding) • Cracking or eczema • Gross deviation of the nipple • Bleeding or discharge • Areola : observe for • Abnormal reddening • thickening
  10. 10. INSPECTION: • Ask the patient to raise her arms above her head (important for examination of axilla and axillary tail) • Ask the patient to place hands on hips and apply downward pressure. • Inspect the breast while patient is lying flat. • Inspect the axilla , arms and supraclavicular fossa.( Grossly enlarged LNS/ veins/ edema) may be visible. • Healthy women may have some
  11. 11. BREAST PALPATION: • Patient lies on the the couch , lying flat with pillow behind the head. • Arms by her side or behind her head. • Palpate with the flat of the finger using middle three fingers. • Either begin with the normal side or feel both the breast together. • Get on level with the patient. • Use rotatory motion to gently press the breast tissue against the chest wall. • Palpate the axillary tail which lies on the anterior axillary tail. • LUMP : site , size, shape, surface ,edge, and consistency. Bi-manual examination controlling movement of the lump with one hand and feeling with the other.
  12. 12. BREAST PALPATION: • Examine the breast systematically , covering the whole cone of the breast tissue using one of the following 03 methods • 1. zigzag 2. concentric. 3.cricular • A systemic methodological exam, covering all four quadrants, axillary tail, areola and nipple. • With large breast use one hand to steady the breast.
  13. 13. SYSTEM OF THE BREAST PALPATION 1/ZIGZAG • The examiner zigzags up and down • Preferred method for self examination • Advantage: Breast tissue remains in contact with the chest wall during palpation.
  14. 14. SYSTEMS OF THE BREAST PALAPATION 2/ CIRCULAR • Breast tissue is examined using a circular approach • The examiner starts at periphery and ends at the areola and nipple.
  15. 15. SYSTEMS OF THE BREAST EXAMINATION 3/RADIAL • The examiner divides the breast in series of segments • The quadrants are examined methodically, from periphery towards nipple • The examiner traces a pattern similar to a clock.
  16. 16. THE AXILLA: • To examine the axillary tail, ask the patient to rest her arms above her head • Feel the tail between thumb and fingers( extends from the upper outer quadrant towards axilla).
  17. 17. NIPPLE AND AREOLA: • To examine the nipple; hold the areola between thumb and fingers. • Gently compress, attempting to express discharge. • Note color of any discharge, send for cytology. • Cover the patient .
  18. 18. EXAMINATION OF AXILLA: • Stand on the patients right side. • Patients arm is raised and supported. • Take hold of right elbow with your right hand and let her forearm rest on your right forearm. • Place your left hand flat against the chest wall and feel for any glands by sweeping tips of your fingers to catch the glands against the chest wall. • Slightly cupped hands are then inserted into the apex of the axilla ( push firmly). • To examine the left axilla, move around to the left axilla hold her left elbow with your left hand and use your right hand to feel the axilla. • Palpate the clavicular fossa and the neck. • Note No, size and consistence of any glands
  19. 19. GENERAL EXAMINATION: • Check the arms for swelling or any neurological/vascular abnormalities. • Palpate the abdomen, look for hepatomegaly/ascites. • Examine the lumber spine for pain or restricted movements.
  20. 20. RECORDING AND INVESTIGATIONS: • Identify which quadrant and which breast. (Right upper outer quadrant) • Best to record graphically. • TRIPLE ASSESMENT: • women with suspected cancer receive triple assessment, which consists of • 1. HISTORY AND EXAMINATION • 2. MAMMOGRAPHY/ ULTRASOUND SCAN. • 3. CYTOLOGY(FNA) OR HISTOLOGY(BIOPSY).
  21. 21. THE NIPPLE: –NIPPLE RETRACTION: –SIMPLE NIPPLE INVERSION: • Retraction occurring during puberty • Bilateral • Of unknown etiology. • May cause infection during breast feeding. • RECENT RETRACTION OF THE NIPPLE: Is of considerable significance. • SLIT LIKE RETRACTION: may be caused by ductal ectasia and chronic pre ductal mastitis. • CIRCUMFERENTIAL RETRACTION: with or without lump indicate carcinoma.
  22. 22. • CRACKED NIPPLE: May occur during lactation. It should be rested for 24-48 hrs. • PAPILLOMA OF THE NIPPLE: should be excised with a tiny disc of skin or the base maybe tied to a ligature and the papilloma will fall off. • RETENTION CYST OF GLAND OF MONTGOMERY: These glands, situated in the areola, secrete sebum. • If blocked can cause sebaceous cysts. • ECZEMA: Rare, often bilateral. Treated with 0.5 per cent hydrocortisone. • PAGETS’S DISEASE: Occurs due to malignant cells in in the subdermal layer. • Usually associated with carcinoma. • Should be differentiated from eczema. • Nipple is eroded slowly and eventually disap- pears.
  23. 23. DISCHARGE FROM THE NIPPLE: • DISCHARGE FROM THE SURFACE: • Paget’s disease • Eczema, psoriasis • Discharge from a single duct: Blood stained • Intraduct pailoma • Intraduct carcinoma Serous stained • Fibrocystic disease • Duct ectasia • DISCHARGE FROM MORE THAN ONE DUCT: BLOOD STAINED: CARCINOMA BLACK OR GREEN: DUCT ECTESIA PURULENT: INFECTIONS SEROUS: FIBROCYSTIC DISEASE MILK: LACTATION
  24. 24. CONGENITAL DISEASES OF THE BREAST: •Amazia: congenital absence of the breast. • It is associated with absence of the sternal potion of the pectoralis major(POLAND’S SYNDROME) • More common in males. •POLYMAZIA: Accessory breasts •Most commonly occur in axilla, groin and buttock.
  25. 25. • MASTITIS OF INFANTS: Milky secretion on the 3rd or 4th day of life, if the breast is slightly pressed down. • It is physiological. • Caused by stimulation of fetal breast by prolactin due to drop in maternal oestrogen. • TRUE MASTITIS: Relatively uncommon caused by staph aureus.
  26. 26. •Diffuse Hypertrophy: •The breast attain enormous dimensions. •In early puberty or 1st trimester of pregnancy. •Rarely unilateral •Due to the alteration of the normal sensitivity of the breast to oestrogen. •Treatment: Anti-oestrogens or reduction mammoplasty.
  27. 27. INJURIES OF THE BREAST: • H E M ATO M A : G I V E S R I S E TO A L U M P • T R A U M AT I C FAT N E C R O S I S : M AY B E A C U T E O R C H R O N I C , U S U A L LY O C C U R S I N S TO U T M I D D L E A G E D W O M E N . • F O L LO W I N G A B L O W. • P R E S E N T S A S A PA I N L E S S L U M P. • M AY M I M I C A C A R C I N O M A . • D X : B I O P S Y ( H I S TO R Y O F T R A U M A I S N OT D I A G N O S T I C )
  28. 28. ACUTE AND SUBACUTE INFLAMMATION OF THE BREAST • BACTERIAL MASTITIS: Most common variety • Associated with lactation. • Caused by S.aurues (mostly staphylococcus present in the infants nasopharynx) • PRESENTATION: Classical signs of acute inflam- mation • Early on presents as cellulitis later an abscess will form. TREATMENT: 1. Antibiotics (flucloxacillin/ co-amoxiclav)
  29. 29. • Local heat and Analgesia for pain. • Infection not resolved for 48 hrs. : Incisi- on and drainage. • Or repeated incision using antibiotic cover. • TUBERCULOSIS OF THE BREAST: • Rare. • Associated with active pulmonary TB or TB cervical adenitis. • PRESENTATION: Multiple chronic sinuses and abscesses. • Bluish appearance of the surrounding skin. • DX: Bacteriological and histological examin- ation. • TREATMENT: Anti- TB chemotherapy. • Mastectomy in persistent cases.
  30. 30.  M O N DO R’S D I S EAS EOF T H E B R EA S T Thrombophlebitis of the superficial veins of the chest and ant. Chest wall. In the absence of injury cause is unknown. PRESENTATION: Thrombosed subcutaneous vein .attached to the skin. When the arms are raised, a shallow groove appears. TREATMENT: RESTRICTED ARM MOVEMENTS/RESOLVES SPONTANEOUSLY.
  31. 31. DUCT ECTASIA/ PERI-DUCTAL ECTASIA
  32. 32. DUCT ECTASIA/PERI DUCTAL MASTITIS: • It’s a dilation of the breast ducts. • Often associated with peri-ductal inflammation. • COMMON IN SMOKERS( increases the virulence of commensal bacteria). • PATHOGENESIS; Disorder of dilation in one or more lactiferous ducts. • Which fill with brown or green secretions>discharge> irritation> periductal mastitis. • CLINICAL FEATURES: • Sub areolar mass. • Nipple discharge. • Abscess. • Fistula of mammary duct. • Nipple retraction(slit like) due to fibrosis. • TREATMENT: In case of nipple retraction and mass carcinoma must be excluded • Antibiotic therapy. • SURGERY: HADFIELD’S OPERATION( EXCISION OF ALL THE MAJOR DUCTS).
  33. 33. CARCINOMA OF BREASTB R E A S T C A N C E R I S O N E O F T H E L E A D I N G C A U S E O F D E AT H I N M I D D L E A G E D W O M E N I N W E S T E R N C O U N T R I E S . T H E I N C I D E N C E I S T H O U G H T TO C O N T I N U E R I S I N G A LT H O U G H M O R E S L O W LY T H A N P R E V I O U S LY D U E TO R E D U C E D U S E O F H R T D R U G S .
  34. 34. AETIOLOGICAL FACTORS: • 1.GEOGRAPHICAL ( mostly occurs in western countries 3-5% death in all women) • 2. AGE( extremely rare before age of 20,incidence rises so that at 90yrs almost 20% are effected) • 3.GENDER (< 0.5% are male) • 4. GENETIC( occurs most commonly with family history) • 5. DIET( alcohol consumption and links with diet low in phyto-oestrogens. • 6.ENDOCRINE ( most commonly in nulliparous women, post menopausal obese women, long term use of combined preparation of HRT); ( breast feeding and having first child at an early age is thought to be protective). • 7.PREVIOUS RADIATION ( Women who have been treated with mantle radiotherapy in Hodgkin’s disease, risk appears after a decade of radiation therapy)
  35. 35. PATHOLOGY:  Breast cancer may arise from the duct system anywhere from the nipple end of the major lactiferous ducts to the terminal duct unit , which is the breast lobule.  Disease maybe entirely in situ.  Degree of differentiation: 03 grades ( well differentiated, moderately differentiated or poorly differentiated)  Commonly, numerical grading system : Based on 3 factors is used  1. Nuclear pleo-morphism  2.Tubule formation  3. Mitotic rate  With grade 3 equating to poorly differentiated group.  On the basis of gene analysis 05 types have been identified.
  36. 36. INVESTIGATION OF BREAST LUMP USING FINE NEEDLE CYTOLOGY • CYSTIC : Lump disappears ,clear fluid Discharge patient Residual thickening, blood stained fluid. Investigate/core biopsy • SOLID : Benign Offer excision or observe Atypical Investigate/ core biopsy Malignant Treat for cancer.
  37. 37. NOMENCLATURE OF BREAST CANCERS: • 1.DUCTAL CARCINOMA ( most common variant, DCIS classified using Van Nuys classification, combines age, type, presence of micro calcifications, extent and size of disease) • 2. LOBULAR CARCINOMA( 15% of cases , E-cadherin antibody positive, on immuno- histochemical assay, multifocal and bi-lateral, MRI for assessment) • 3.MIXED • 4.COLLOID OR MUCINOUS CARCINOMA(rare, better prognosis, contains abundant mucin) • 5.MEDULLARY CARCINOMA(solid sheets of cells, marked lymphocytic reaction, • 6.INFLAMMATORY CARCINOMA( rare, highly aggressive, presents as painful, swollen breast ,warm with edema, mimics an abscess
  38. 38. PAGET’S DISEASE OF THE NIPPLE:
  39. 39. SPREAD OF BREAST CANCER: • LOCAL SPREAD: ( Tends to involve the pectoral muscle and chest wall if dx late) • LYMPHATIC SPREAD: ( To Axillary and Internal mammary nodes, involvement of contralateral and supra clavicular nodes represents advanced stage) • SPREAD BY THE BLOOD STREAM( via this route skeletal metastasis occurs) • Order of frequency ; 1. Lumber vertebrae 2.Femur 3. Thoracic vertebrae 4.Ribs and Skull. • Metastasis also commonly occurs in the liver, lungs and brain.
  40. 40. CLINICAL PRESENTATION/STAGING: • Breast cancer is most frequently found in upper outer quadrant. • Mostly present as hard lump, with in drawing of nipple. • Skin maybe involved with peau d’orange appearnce. • Cancer may involve the chest wall and known as cancer-en- cuirasse. • STAGING: by means of TNM( tumor node metastasis) OR UICC UICC (Union contre le cancer) • Staging evaluation Includes: careful clinical examination , chest X ray, CT of the chest and abdomen and isotope bone scan.
  41. 41. TREATMENT OF CANCER OF THE BREAST: • Two basic principles: 1. To reduce local recurrence 2. To reduce risk of metastatic spread. • Early breast cancer: surgery with or without Radiotherapy(local treatment). • Systemic therapy i.e. Radiotherapy and chemotherapy is added when worse prognostic factors present such LN involvement. • Chemotherapy include Herceptin if Her-2 positive. • Hormone therapy: if oestrogen receptor or progesterone receptor positive. • It’s a Multidisciplinary team approach: Good-patient communication
  42. 42. SURGERY: • Plays a central role. • Trials have shown equal efficacy between mastectomy and local excision. • Mastectomy: indicated for large tumours, central tumours beneath or involving the nipple, multifocal disease, local recurrence. • MODIFIED PATEY MASTECTOMY: More commonly used. • The breast and associated structures are dissected en bloc. • The excised mass is composed of: • The whole breast • Large portion of skin, always includes the nipple. • All of the fat, fascia and LNS of the axilla. • Pectoralis muscle is either retracted or divided to gain access to the axilla. • The veins and nerves to the serratus anterior and litissimus dorsi are preserved. • The wound is drained using wide bore suction tube. • Early mobilization and physiotherapy is encouraged.
  43. 43. CONSERVATIVE BREAST CANCER SURGERY:• Removes the tumour plus a rim of at least 1cm of breast tissue. • Commonly referred to as wide local excision. • Lumpectomy is used for benign tumours excision. • Quadrectomy: includes removing entire segment of breast containing the tumour. • Both of these surgeries include AXILLARY SURGERY via separate incision. • SENTINAL NODE BIOPSY: Standard in management of the patient in node negative disease. • Axillary surgery is done to stage the patient, presence of metastatic disease in axillary nodes is the best marker for prognosis. • Higher rate of recurrence even combined with radiotherapy.
  44. 44. • RADIOTHERAPY: • In higher risk patients radiotherapy to the chest wall after mastectomy is indicated. • Includes large tumours, high risk of recurrence, large no. of positive nodes,or extensive lympho-vascular invasion. • Local excision is combined with radiotherapy as excision alone has very high recurrence rates. • ADJUVANT SYSTEMIC THERAPY: • Outcome of the treatment depends on the extent of MICROMETASTATIC DISEASE. • Systemic therapy targeting these micro-metastasis delays relapse and prolong survival. • Adjuvant chemo or radiotherapy will improve relapse free survival rate by 30%. • HORMONE THERAPY: • Tamoxifen most widely used. • Reduce annual recurrence by 25%. • Others agents includes ;LHRH agonists induce reversible ovarian suppression. • AIs (oral aromatase inhibitors) for post-menopausal women.
  45. 45. CHEMOTHERAPY: • Using first generation regimen such as; • Six monthly cycle of cyclophosphamide, methotrexate and 5-flurouracil. • Reduce 25% reduction in relapse for 10-15 years. • Anthracycline(doxorubicin) over CMF considered in newer regimens. • Follow up: follow up for life yearly or two yearly mammography recommended.
  46. 46. • PEAU D’ORANGE: • Resulting from lymphatic obstruction in advanced breast cancers. • Cause by cutaneous lymphatic oedema. • Appears as purple or red color of the skin with pitting or thickening of skin, resembling an orange peel. • Late edema of the arm is troublesome complication of breast cancer treatment. • Due to lymphatic and venous blockage. • Limb elevation, elastic arm stockings and pneumatic compression devices are helpful.
  47. 47. TREATMENT MODALITIES: • Breast reconstruction can be offered immediately after mastectomy. • Silicone gel implant under the pectoralis major muscle. • Musculocutaneous flap can be constructed using latissimus dorsi (LD flap) or tranversus abdominis muscle (TRAM FLAP). • Screening: by mammography in women over 50 yrs is recommended.
  48. 48. CARCINOMA OF THE MALE BREAST: • Less than 0.5% cases. • Predisposing causes : gynaecomastia, endogenous and exogenous steroids. • Presents as as LUMP. • Mostly commonly as infiltrating ductal carcinoma. • Treatment : local excision with mastectomy.

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Breast Examination and Diseases.

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